MAIN FUNCTION:
Functions as a core member of the inpatient unit with emphasis on clinical assessment of patients for this level of care through specialized training on DSM-IV/DSM-V and ASAM criteria for substance use disorders. Interacts in a timely and professional manner with referral agencies for admission processes. Works independently within his/her scope of care in providing nursing assessment and attending to medical needs for patient admitted to the unit. Maintains daily contact with the Staff Medical Director to review necessary orders, request consultations, and update on pertinent health status of patients This position is responsible for the clinical oversight of staff LPN's on the ARU. Completes the admission and intake process necessary for confirming diagnosis, and assessing for any medical/psychiatric condition that could not be safely treated on this unit with staffing skill mix. Provides and assists in admission assessment with the physician. Responsible for the routine nursing care of the patients and provides patient education on self-administration of medications, and any related physical condition as appropriate. This position needs to independently render nursing care in emergency situations. Reports to the Director of ARU.
DUTIES AND RESPONSIBILITIES:
Performs and documents appropriate nursing assessments upon admission in accordance with unit policy and procedures, including identifying primary complaint and initiating immediate interventions from the clinical assessment. Provides a review to and communicates with the Team a brief overview of the admissions current status and immediate needs.
- Performs ongoing nursing assessment as indicated by change in patient's status, medical orders or as directed by unit specific standards. Measures and documents assessment of patient's vital functions. Assesses patient status during emergency code situations and initiates ALS protocols.
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Initiates care in accordance with physicians' orders.
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Administers prescribed medication according to facility and nursing policies/procedures and follows the five rights for medication administration.
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Accurately and chronologically documents all patient care, assessments, treatments, medication administration, etc. legibly and using only appropriate abbreviations.
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Serves as patient advocate, providing an individualized standard of care and addresses the patient's physical, emotional, spiritual, educational and psychosocial needs.
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Recognizes and adapts care to meet the patient's individual needs including: health issues, interventions, goals, care plan, age, comprehension level, physical disabilities, sensory deficits, cultural beliefs, and language differences.
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Provides education regarding the patient's health issues and on-going care to patients and family members. Adapts teaching plan to the age and comprehension level of the patient. Evaluates and documents effectiveness of patient/family education.
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Performs duties in compliance with New York State OASAS part 818 regulatory requirements, DNV, DOH and facility policies for patient, environmental, and personal safety.
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Adheres to universal precautions and all safety policies and procedures.
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Serves as a preceptor for new employees and students during individualized clinical experiences as assigned.
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Delegates tasks and duties to coordinate patient care and health activities amongst the healthcare team, including evenings and weekends.
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Monitors nursing staff to assure they are following established safety regulations in the use of equipment
and supplies, such as the initial and annual trainings for competent use of the Breathalyzer machines.
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Assists in the monitoring and review of compliance logs for Department of Health regulations (e.g.
refrigerator temperatures, Breathalyzer temperatures, etc.)
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While fulfilling supervisory responsibilities, Heath Care Coordinator will take immediate corrective action, if needed, and reports problems or concerns promptly to the Director.
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Has primary role in handling initial contacts from referral sources for admissions to obtain base
line information to confirm diagnosis and to assess any medical condition which could not be
safely treated on this unit (i.e. those requiring 24-hour nursing care etc.). Information will include
current medications and current medical/psychiatric status. Medical Director is consulted, whenever
necessary, to determine if unit has staffing appropriate to handling patients' medical needs.
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Confirms insurance coverage in place and performs necessary Utilization Review as required. Conducts face-to-face pre-admission assessment as required by insurance agencies.
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Sets up admission date/time with referral source or patient. When patient is referred from an
acute unit of the hospital (i.e. detox), BSU, or Emergency Room, this role coordinates admission.
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Upon admission conducts nursing assessment appropriate to acuity of care.
Performs nursing-specific admission duties.
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Arranges for history & physical evaluation by physician assigned to the unit within 24 hours of admission. Any medical questions are relayed to the Medical Director.
Sets up medications in the pyxis and verifies that medication orders are accurate.
- Provides initial orientation of patient to the unit - including review of confidentiality, smoking
policy, grievance procedure, Patient Handbook, introduction to patient's "buddy" and primary
therapist. Tours the unit with patient, and generally takes steps to assist patient in making the
initial transition into this new setting.
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Provides face to-face Chemical Dependency Evaluations through consultation to the Emergency Room, the BSU, Mixed Medical, or other areas of the hospital for patient seeking admission to the hospital for detoxification and/or to the unit. Assesses eligibility and appropriateness for inpatient level of care, as ordered by attending physicians (e.g. BSU, hospitalist, ED, etc.).
- Continues to provide nursing assessment in addressing patients' physical complaints or
observed symptoms during the course of treatment to determine need for physician, or for
immediate acute care; institutes treatment within scope of care; and appropriately reassures
patient who is in distress.
Findings from physical assessments are documented with appropriate interventions. Analyzes assessment data to determine appropriate medical diagnosis. Formulates goal-directed plans of care that are incorporated into the treatment plan, which is prioritized and based on medical diagnosis and expected patient outcomes. Reviews treatment plans on a regular basis to ensure treatment compliance and updates treatment plan as needed.
Arranges discharge and/or transfer to medical or psychiatric service, if needed.
Renders patient-centered care to meet the routine health care needs of patients.
- Performs individualized assessment of patient's educational needs and provides tools to aid patients in
managing their needs.
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Reviews lab and test reports. Consults with the physician if needed to be notified of abnormalities.
May also review lab reports with patients and provide education on how chemicals have or will impact
their health.
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Monitors and records weekly weights of patients.
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Changes dressings, removes sutures, and assesses any new or existing injuries and monitors for worsening of symptoms.
Arranges for nutritional assessment and follow-up.
- Communicates medical information to the treatment staff/team. Consistently identifies health care needs
and updates care plan on a regular basis; delivers care according to the plan.
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May conduct health education classes for patients, including "Rules and Expectations" group,
instruction on use of laundry facilities by patients, explain medical necessity of certain unit rules
and expectations of patient behavior.
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Monitors lifestyle factors affecting health, such as tobacco use, substance abuse, nutrition and physical
activity, and assist patients with goal-setting to achieve behavioral change.
- Monitors patients frequently for changes in health status after initiation of a new medication, an acute
hospitalization, and/or recent decline in functioning.
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Conducts patient and staff education sessions on subjects within professional training, such as
hygiene and self-care, nutrition, psychopharmacology, diabetes management education etc.
Orders, obtains, and maintains all necessary medical and emergency supplies.
- Performs on-call duties as needed; May be contacted at home by ADN's and non-nursing staff with
patient care health concerns.
- Shares responsibility for general facility functions as appropriate to shift, such as unit
cleanliness, processing phone calls, transferring patients to and from other services within the
hospital (i.e. dentist, hair cuts etc), ordering supplies, maintaining patient admission packets,
filing old and new charts, etc.
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Attends and participates in unit Performance Improvement chart reviews.
Participates in Chart Reviews on a rotating basis with other Core team of the unit.
- Attends and participates in the Incident Review Committee meetings as scheduled for the department.
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Will adhere to the Canon of Ethical Principles for credentialed Alcoholism & Substance Abuse
Counselors, whether or not credentialed, or whether covered under any other Canon of Ethics.
This Canon is covered in Part 853 of Title 14 of the Mental Hygiene Lay (Ref: 853.7 [2] [I-xvii])
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Promotes and fosters the mission and philosophy of the Hospital during performance of job
duties and community activities.
Actively supports and participates in Hospital's Performance Improvement endeavors.
- Is responsible for attending all annual mandatory educational programs as required by position.
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Employee understands and demonstrates the importance of satisfying the needs of the customer/patient by interacting with him/her in a friendly and caring way, being attentive to the patient's needs, both psychologically and physically, and by taking the initiative to maintain communication with the patient in order to provide a secure and pleasant experience with Arnot Health.
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Performs other related duties as assigned. It is understood that this job description lists typical duties for the classification and is not to be considered inclusive of all duties which may be assigned.
EDUCATION:
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Current New York State Registered Nurse Licensure.
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BSN preferred
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Three (3) years experience in medical/surgical area or equivalent as the Registered Nurse is required to work in an area without other nursing personnel for reference.
- Prefer psychiatric or chemical dependence assessment experience/training.
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CASAC,preferred.
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Experience in a related rehabilitative setting, such as physical rehab, TBI rehab unit, community nursing
etc, where educational counseling, and supportive interaction is stressed.
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Knowledge of alcoholism and chemical dependency sufficient to understand the underlying principles and how it relates to the rehabilitative treatment setting for expectation of patients, Post Acute Withdrawal symptoms and how they manifest in the patient, and the effect of medical conditions in this context to adequately care for the patient.
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Some training or background in counseling skills strongly preferred - experience in a behavioral health setting with good understanding of chemical dependency is desirable.
CARDIOPULMONARY RESUSCITATION (CPR) REQUIREMENTS:
Basic Life Support (BLS) required within 90 days of hire date and annual renewal.
PHYSICAL DEMANDS:
Appreciable physical effort required. Some lifting, reaching and stooping. Required to be on feet much of the time.
EXPOSURE CATEGORY:
Category I. Tasks that involve exposure to blood, body fluids or tissues.
